Please print and fill in the form with the required information.

• Players must present the completed form with current and valid identification to the Cashier.
• Forms will be processed and the Win/Loss Statement will be mailed to the provided address.
• Forms are also available at Indiana Live! Casino at the Cashier Window and Live! Rewards Counter.

Choose from a compatible file format below (both forms are the same):

Adobe Acrobat Format

Microsoft Word Format